In August 2010, the maker of the prescription painkiller OxyContin released an abuse-resistant formulation of the drug to deter addicts from crushing it and inhaling or injecting it. The new pill had a dramatic effect: OxyContin went from being the primary drug of abuse for 36% of prescription-drug misusers to just 13% about 21 months later, according to a letter published Wednesday in the New England Journal of Medicine (NEJM).

Problem is, this didn’t mean that drug users quit when they stopped getting high on OxyContin. Instead, they simply switched drugs. As abuse of OxyContin (oxycodone) fell, other opioids moved in to fill the gap: drug users choosing high-potency fentanyl and hydromorphone rose from 20% to 32%, according to the NEJM survey. When asked about the drugs used to “get high in the past 30 days at least once,” OxyContin fell from 47% of respondents to 30%, while heroin use nearly doubled.

As USA Todayreports, the opioid Opana (oxymorphone), which was introduced in 2006 without a mechanism to deter misuse, is now more commonly used than OxyContin. But in June, a new abuse-resistant version of Opana hit the U.S. market. Experts say the move will simply cause drug addicts to shift again, not to quit. As the NEJM article shows, illegal heroin use will rise to meet opioid demand when prescription drugs become undesirable, too expensive or scarce. The authors quote one survey respondent as saying: “Most people that I know don’t use OxyContin to get high anymore. They have moved on to heroin [because] it is easier to use, much cheaper and easily available.”

The study included nearly 2,600 people who entered treatment programs around the country for prescription opioid addiction between July 2009 and March 2012. At admission, they were surveyed about their drugs of choice. Based on the data, the authors conclude:

[A]n abuse-deterrent formulation successfully reduced abuse of a specific drug but also generated an unanticipated outcome: replacement of the abuse-deterrent formulation with alternative opioid medications and heroin, a drug that may pose a much greater overall risk to public health than OxyContin. Thus, abuse-deterrent formulations may not be the “magic bullets” that many hoped they would be in solving the growing problem of opioid abuse.

The finding should be entirely predictable for anyone who knows anything about addiction. While it may be possible to prevent some new cases of addiction by reducing the supply of particular drugs, the strategy does nothing for existing cases, and it may simply cause people who would have become addicted to one drug to become addicted to another.

That’s because addiction doesn’t reside in a drug. Rather, it results when the widespread human desire to manage emotions becomes dysfunctional in some cases of some people meeting some drugs in some circumstances. That dysfunctional coping strategy, which leads to addiction, isn’t “cured” merely by removing one of the tools it relies on. In other words, the problem is not the drug, but the need for it.

When doctors simply cut off patients whom they discover to be misusing drugs, or when pharmaceutical companies introduce abuse-deterrent formulas, the need that drives addiction remains unaddressed. Pushing addicted people into the market for street drugs actually worsens the situation: they are now out of contact with the medical system, the drugs they get are far more likely to be adulterated or even poisonous, and they no longer have good knowledge of the dose they’re getting, which increases overdose risk.

The dirty secret, therefore, is that prescription drug misuse is safer than heroin use — not because the inherent overdose or addiction risk is any lower with prescription opioids, but because these drugs come in known doses with specific ingredients and often involve contact with a medical doctor. Consequently, instead of viewing addicts as criminals who con doctors and deserve to be cut off — and instead of focusing on clever technologies to defeat their attempts to get high — we should be looking at why they so desperately want to take drugs to escape in the first place.

The most effective known treatment for opioid addiction is maintenance treatment with another opioid, typically methadone or buprenorphine (Suboxone, Subutex). Such treatment reduces the spread of blood-borne disease, cuts crime and saves lives better than any other known method. It may be that the maintenance opioids help treat depression or act as a salve for some other underlying problem, allowing some people to function better on the drugs than off. Whatever the case, people can and do lead full, productive loving lives of recovery while taking these medications. Add appropriate counseling, job training and psychiatric medication where needed and you can sometimes see even better results.

Rather than driving prescription opioid misusers to the illegal heroin market, then, we should be pushing them in the other direction: trying to get as many opioid addicts as possible into the medical system and using opioids themselves in treatment when necessary. It may seem counterintuitive, but effective strategies often are.

I used to use oxycontin, but since the new formula came out I have used heroin! I do not use full time, but i use 6-10 days per month and heroin costs a whole hell of a lot less than oxycontin and it gets you five times higher so it's a no brainer for most people to switch to heroin! i don't iv either, i insufflate so the new formula made it really difficult to abuse, and i have heard the new formula has some really dangerous additives in it, and ive known people who have eaten a whole op oxycontin pill and pooped the whole pill out, and i have heard the side effects are worse than the old formula was, so good job purdue, all you did was make your produce less effective, more harmful, and you pushed millions of people to use heroin instead of oxy, good job! heroin dealers are the big winners in this scenario, they are the only winners actually!

Drug replacement therapy should only be used to treat acute cases of addiction withdrawal as part of the medical detox process. Rehab centers that use DRT as a long-term method of recovery are being irresponsible. The "Non 12 Step" approach as outlined here http://www.drug-alcohol-rehabs.org/non-12step-drug-rehab.html is the safest, most effective way to treat addiction.

i totally disagree about methadone treatment i had an addiction to herion in my twentys for about two years i managed to turkey of it when a good friend died of overdose in my early thirtys i lost my parents had stillborn child it goes on and on i was suicidle the doc put me on anti depressannts made me worse i did not want to go back to herion so i started taking dhc,s and diazipam it solved all my proplems i started geting my life back together started running swimming .my problems started when i could not get the dhcs i went to drug addiction or funnily enough rehab they put me on 18 mill of subutex iv,e a rolling hyitis hernia il have for the rest of my life then they put me on methadone increasing up to 85ml i have ended up with collapsed lungs phenmonia and from taking 2 inhalers a year to talking about 30 inhalers in 3 years its a disgrace 10ml of meth is like 300ml of dhc,s which was my addiction they would not give me dhcs but had the cheek to put me on 85ml meth 850ml dhc,s has anyone been treated like this or found methadone has wrecked there chest and life

So much of addiction discussion and treatment is symptom chasing. The behavioral symptoms are not the disease -- the underlying, permanent birth defect of a broken dopamine system is the medical cause.

Focusing on the hyper-seeking and using is like talking about heart disease as shortness of breath and trying to increase lung capacity -- or, more accurately, stopping people from huffing and puffing.

By definition, if the hyper-behavior could be stopped, people wouldn't have an addition. Also, like any illness, some people have it to different degrees.

I don't know what's the sadder, the circumstances you describe or the fact that it's surprising to see an informed, informative, and compassionate article describing said circumstances.

But thank you for writing it. I will optimistically take it as a sign that the times are changing, and that we're heading for a new age of reason and humanity with respect to prohibition. There's no one-size-fits-all explanation for drug abuse and it's willfully stupid to label all these people "criminal" just for the benefit of the prison industry.

If one begins with the assumption that addiction is a disorder as opposed to a failing of will, then it becomes much more reasonable to try to treat it rather than deride it. There are individuals with addictive behaviors who seek the high to the exclusion and detriment of everything else - even life itself. They have no apparent control over these acts. Whether a lack of personal will or a disorder, the treatment for this is the same - controlled maintenance. It's not the addiction itself that causes the problem. It's the escalation of the addiction to larger and greater highs as tolerance is built up.

With therapy and maintenance, the addiction can be controlled. Every study ever done has shown that addiction therapy is more effective in both time, money and effort in stopping the associative behaviors of addiction - including crime - than punishment or imprisonment. Yet we imprison and punish instead of treat at great cost to society.

There are those whose sensibilities are apparently offended by not hurting those who hurt others or themselves. Their sense of "justice" isn't fulfilled unless those who do these aberrant behaviors experience equal or worse discomfort. That kind of neanderthal thinking has to be replaced by rational thinking in cases of drug addiction - preferably BEFORE we run out of prison space (not to mention the funds to keep those prisons running).

Most chronic pain patients who use opiates do not become addicted. Articles like this put the onus on those who use these drugs to get through the day, for some people an opiate the only medication that allows them to physically get out of bed. The reason the abusers went to another drug was because they were abusers, not people with true medical problems that require narcotic medication.

Those in chronic intractable pain do not enjoy, for the large majority, the sensation that these drugs give, cloudiness, drwosiness, dry mouth, etc. We do not doctor shop or buy and sell these meds illegally.

Articles like these need to differentiate between misusers and abusers versus the majority who use these medications as prescribed.

heroin is still very expensive man, you make is sound like heroin is as cheap to buy as weed is, it isn't. most heroin dealers sell .5 grams for 50 dollars, so basically $10 per .1 gram of heroin or $100 per gram. unless you buy in bulk it is very expensive, and dealers who have pure stuff sell it for more like $150 to $200 per gram. that is very expensive for most people. especially once you get hooked and you need a gram a day to make you feel good, thats around $100 bucks a day, that is real expensive obviously! but yes it is much cheaper than buying oxycontin on the street, which costs $1/mg or thereabout, but i totally agree with you about the severity of the problem. me and my friends around 2002-2003 all discovered oxycontin and we all slowly but surely got hooked, and most of us ended up using heroin and many of us have even overdosed at one point or another. and the majority of us are now on suboxone to keep us straight, but for me in particular i still use recreationally, but at least im not a junkie anymore! once you let opiates take over your life, life is never the same again, but i know people who got out of the life and are totally clean now, but they are the rare ones, most of us end up addicted to opiates for the rest of our life in one way or another. its a tough battle, but we have no one to blame but ourselves!